Why doesn't pigmentation improve after lasers?

In my years of skin and aesthetics practice, I’ve met lots of patients who asked me this question.

The answer is simple; there are 4 factors that determine a successful laser treatment. When any of these go wrong, you will NOT see results.

1. Pre and Post Care Compliance

This is the ‘easiest’ factor because it is within your control. To get best results with lasers, you ABSOLUTELY have to follow your doctors’ instructions. Make sure you are compliant with skincare products like lightening cream, sunscreen (especially!) and sun protection measures, both before and after treatment.

A big reason for pigmentations not improving, or turning worse (getting darker instead of lighter) is failure to comply. Listen to your doctor’s pre and post care advice carefully and adhere to the maintenance regime.

See what happens below when you don’t respect sun damage enough:

Sun Induced Hyperpigmentation

Sun Induced Hyperpigmentation

Key Advice #1: If you can’t avoid the sun, make sure you apply sunscreen at least 1-2 times daily.

2. Correct Diagnosis

Diagnosis is the basic skill of a skincare doctor but do not take it
for granted. Different types of pigmentation require different kinds of
treatments.

“But a qualified skincare doctor should be able to identify my condition easily, right?”

Not really. People often have mixed pigmentation on their faces so it can at times be difficult for a doctor to diagnose. The doctor’s clinical experience (vs. just studying theories from textbooks) in pigmentation is very critical to applying the correct diagnosis and thus, suggesting the most effective laser method.

Here are some examples of my existing patients with different pigmentations:

Melasma

Hori's Naevus

Freckles

Solar Lentigo

Post-inflammatory Hyperpigmentation

Pigmentation Bumps (seborrheic keratosis)

A Strong diagnosis is VERY important as the doctor will be able to advise on specific type of treatment, number of sessions, costs required and what kind of results to expect.

Key Advice #2: Research on your doctor and be sure he/she is very experienced with pigmentations.

3. Clinical Skill with Pigmentation Lasers

This is a big reason why patients complain of poor results. Most
laser treatments (e.g. Q-switched Nd:Yag laser) look like regular
zapping. It’s not that simple as the doctor has to decide on which treatment settings to give optimal results.

I had a patient with Hori’s Naevus who complained that her previous
doctor hardly gave her results but complimented that there was almost no downtime. I immediately realized that her previous doctor had set the laser strength TOO LOW. Why? Because Q-Switched laser on Hori’s Naveus will need to create
redness and swelling for at least a few days to get desirable results.
If the strength is too low, then of course there’s also no downtime!

Conversely, if the laser is set TOO STRONG during the hyperpigmentation treatment, it can create complications like post-inflammatory hyperpigmentation (darker spots) and confetti hypopigmentation (white spots).

These can take months to years to resolve.

post inflammatory hyperpigmentation

Hypopigmentation

PIH (darker spots) on the left and Hypopigmentations (whiter spots) on the right.

Question is, how to tell if the doctor can give results BEFORE signing up for treatment?

Key Advice #3: Ask the doctor for their before/after photo
album of previous patients. Make sure it is substantial and not just a
few photos.

4. Laser Technology

I get worried for patients who ask “Does your clinic have this XYZ laser?”

Not because I don’t have it, but because they think that having a new, high tech XYZ laser alone can give magical results.

It does not and usually only results in higher prices for the patients. For example, I use Q-Switched Nd Yag Laser vs. the new Pico Laser. The
Q-Switched laser is much more affordable yet skilled doctors will still
be able to deliver the same results or better.

In medical school, our professors always reminded us to focus on clinical skill and experience while borrowing suitable technology to deliver the best results. I totally agree, so I keep my lasers updated but I do not like to advertise having new machines.

How to tell if my doctor can deliver results on pigmentations?

From personal experience, word of mouth is best. Online reviews can
also give a good idea on what to expect from the doctor. However,
individual experiences can differ greatly. Your close friend might get
amazing results, but 10 others might have been disappointed in the same
doctor.

Thus, the most important thing you should do is to ask your doctor for his before/after album of previously treated patients. (Doctors are NOT allowed to show this to you online or they will get a warning letter from Ministry of Health very soon!)

Singapore has good doctors for treating pigmentation but make sure you do due diligence before committing to a laser treatment.